Bad Grades on CABG Report Card Don't Affect Hospital Market Share


A review of New York state's report card on coronary artery bypass graft surgery has found that mortality risks were 50% lower when the procedure was done by higher-performing surgeons or at higher-rated hospitals, compared with those that were done by lower-performing surgeons or at lower-rated facilities.

However, the study authors—Dr. Ashish K. Jha, of the department of health policy and management at the Harvard School of Public Health, Boston, and Arnold Epstein, chair of the department—also found that the reports, whether positive or negative, did not change hospital market share.

“We found no evidence that purchasers or patients are using these reports to drive market share to higher-performing providers,” they wrote (Health Aff. [Millwood]. 2006;25:844–55).

But the data “seemed to have a critical impact on practicing surgeons' livelihood,” wrote Dr. Jha and Dr. Epstein, who also noted that those surgeons who received lower grades were more likely to retire or stop practicing.

The researchers looked at data collected from 1989 to 2002 as part of the New York State Cardiac Surgery Reporting System.

Hospital data, which are reported annually, include risk-adjusted mortality and the number of cases per facility. The mortality data for individual surgeons were available, but only over 3-year periods. The authors were able to identify those surgeons who had dropped out of reporting and they attempted to follow up with all of them either by phone or e-mail.

To analyze the data, the authors divided hospitals and surgeons into four categories: the top decile, top quartile, bottom quartile, and bottom decile. Thirty-three hospitals performed CABG during the study years. Two were excluded because they had less than 3 years' experience.

CABG hospitals were more likely to be teaching facilities, to be located in New York City, and to be larger, with a mean 644 beds, compared with 315 for non-CABG facilities.

During the study period, 168 surgeons performed CABG.

Overall, patients in top-decile hospitals had an average risk-adjusted mortality of 1.59, compared with 2.78 for those in the bottom-decile facilities.

Those patients who were operated on by top-decile surgeons had a risk-adjusted mortality of 1.58, compared with 3.20 for the patients of bottom-decile surgeons.

After the report card was published, 20% of bottom-quartile surgeons quit performing CABG, compared with 5% of those in the top three quartiles; 31 surgeons—with a median age of 61 years—left practice.

Follow-up data were available on 25 of the surgeons (2 others died): 9 were still doing CABG outside of New York, 9 retired, and 7 had taken nonclinical positions. Of the 18 surgeons who had answered survey questions, 10 said that the report card had not influenced their decision.

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